AUSTIN — Pressure is mounting on Gov. Greg Abbott to let doctors resume some elective surgeries, amid complaints that patients aren’t receiving needed care and hospitals are under financial strain.
Abbott ordered hospitals to delay non-emergency procedures through April 21, in an effort to free up bed space and conserve personal protective equipment to address the coronavirus pandemic.
This week, however, all 31 state senators and the Texas Medical Association urged Abbott to begin slowly relaxing those restrictions.
“We’re asking for flexibility for Texas hospitals to provide needed medical care based on local situations and a physician's medical assessment of a patient, with an understanding that this is all contingent on the availability of PPE and bed capacity,” said Carrie Williams, a spokeswoman for the Texas Hospital Association.
But some health care leaders warn the step could put further pressure on the already tight market for face masks, gloves, gowns that medical staff need to avoid contracting COVID-19, the disease caused by the virus.
State Rep. Donna Howard, D-Austin, said the state must be more transparent about its supply of personal protective equipment before Abbott decides whether to allow more medical procedures.
“In order to move forward it must be done strategically and with every effort made to ensure that we do have sufficient PPE to protect the staff, protect the patients, protect the people who are going to be in contact with anyone involved in this,” said Howard, a critical care nurse. “The PPE has to be addressed. Without it, it’s only going to exacerbate the shortage that’s already there.”
The decision over adjusting the order is likely among the first Abbott will make as he begins the tricky balance of reopening the state, while trying to avoid a surge in new coronavirus cases.
The order has already been a source of controversy after Texas Attorney General Ken Paxton said it included a ban on abortions, which sparked a heated ongoing lawsuit.
Abbott, a Republican, is expected to announce steps for restarting the Texas economy on Friday. His office did not respond to requests for comment.
David Lakey, who formerly led the state’s public health agency, said Abbott had to put the brakes on early to ensure enough bed capacity and personal protective gear. But now with better data and modeling, he said the state can start to slowly relax surgery restrictions in cases where a significant delay would result in serious consequences for the patient.
“This isn’t an on-and-off switch,” said Lakey, who is Vice Chancellor for Health Affairs and Chief Medical Officer at The University of Texas System. “It’s more of a gradual type switch where you slowly release the constraints on the health care system and society and closely watch the situation.”
Medical groups said they are increasingly concerned about the long-term economic impact of the restrictions, particularly for the state’s long-struggling rural hospitals.
Faith Community Health System in Jack County has had to furlough, reduce hours or reassign roughly 75% of staff as revenue from elective procedures has dried up, said CEO Frank Beaman. Meanwhile he said a surge of coronavirus patients has yet to materialize in the county -- northwest of Fort Worth -- where 3 people have tested positive for COVID-19 to date.
“Where larger hospitals might have the ability to sustain that loss of revenue, rural hospitals just don’t. It has hit us faster and harder,” Beaman said. “I am afraid you are going to see rural hospitals have to discontinue essential services, and in some cases, rural hospitals will probably close if that (revenue) hole is not filled.”
State senators also raised concerns about patient care, writing in a letter to Abbott that “critical surgeries involving cancer and other diseases are being delayed for fear that a provider could lose his or her license, fined and potentially face jail time.”
State Sen. Robert Nichols, R-Jacksonville, whose district covers 19 counties in East Texas, said hospitals have told him they are opting against treating patients with serious issues because they are scared to go astray of the guidance and have their doctors’ licenses suspended.
He said hospitals in his district have put off removal of tumors, mastectomies and melanoma treatment because they are not deemed “immediately medically necessary.”
“There's absolute fear to do these procedures that medically should be done but are not considered immediate death type threats,” he said.
Medical groups contend guidance by the Texas Medical Board on the order is too restrictive and say requirements for physicians to report potential violations is creating a chilling effect. Physicians are also wary of a provision in Abbott’s order that could expose them to a $1,000 fine or 180 days in jail if they are deemed to be in violation.
The Texas Medical Association called on Abbott to remove that language from his order.
The Texas Medical Board guidelines are not intended for Texans to forgo “immediately medically necessary surgeries or procedures as determined by physicians,” but are meant to stop egregious violations, spokesman Jarrett Schneider said.
The board has received “many complaints” but has not had to hold any hearings related to violations yet. Other investigations are ongoing, Schneider said.
“TMB wants patients to receive immediately medically necessary surgeries and procedures, as determined by physicians,” he said.
The Texas Hospital Association said members should be able to perform procedures if patients face the threat of permanent organ dysfunction, the risk of cancer progression or if their symptoms could rapidly worsen, among other things.
While the supply of protective gear is still a concern, Nichols said local doctors should be allowed to make those decisions.
“These hospitals, whether it be a stand-alone or a system, they're in a better situation to know whether they have adequate supplies than anyone else,” Nichols said. “Leave that decision to the doctors.”
But concerns remain that allowing some elective procedures could put further strain on the limited supply of personal protective equipment that hospitals, state governments and emergency responders are competing for across the country.
“I think we should consider this very carefully because the market is so tight -- well it’s non-existent in many places,” said Jose E. Camacho, executive director of the Texas Association of Community Health Centers.
The clinics Camacho represents are testing patients for COVID-19 and performing emergency dental procedures. But he has struggled to source enough personal protective equipment to help keep them up and running.
The pandemic has caused an international shortage of personal protective equipment and the state’s health department has said state supplies are limited and will be “distributed to those with the most imminent need.”
Community health clinics like Camacho’s which primarily encounter “suspected cases” are second on the state’s priority list to hospitals that see confirmed COVID-19 patients and have emerging or active outbreaks.
On Thursday morning, Camacho received an offer from a vendor to buy roughly 1,200 N95 respirators for $7.07 a piece -- well over the market rate. By the time Camacho responded a few minutes later, the masks had already been sold to providers in Arkansas and Illinois, he said.
“If we are going to make it through July,” he said, “we need 50-60,000 N95 masks.”
Abbott organized a “strike force” to buy and distribute protective gear statewide. At least 369,000 masks, 681,000 gloves and 53,000 gowns have already been handed out in the Dallas area, according to state data. While hospitals report receiving the protective gear, community doctors said they have received few resources from the state supply.
Medical facilities that are not treating COVID-19 patients are the lowest on the priority list for receiving the state’s supply of personal protective gear, according to a Department of State Health Services document.
A recent survey by the Texas Medical Association found that 74 percent of physicians at risk of running out of protective gear have been unable to order more. Without it, 46% of physicians said they would resort to homemade protective equipment, 37% report they would no longer see patients in the office and 17% said they would refer people to the emergency room.
For doctors like Seth Kaplan, an independent pediatrician in Frisco, being low on the priority list could mean he has to stop seeing patients in person.
He requested gowns and other materials through the state's distribution network, but has never heard back.
“If we don’t have (personal protective equipment),” he said, “we can’t keep our offices open because we have to assume that everybody is potentially contagious when they come in.”
